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Wednesday, November 30, 2011

A hallucination, in the broadest sense of the word, is a perception in the absence of a stimulus. In a stricter sense, hallucinations are defined as Perceptions in a conscious and awake state in the absence of external stimuli the which have qualities of real perception, in That They are vivid, substantial, and located in external objective space. The latter definition distinguishes hallucinations from the related phenomena of dreaming, the which does not involve wakefulness; illusion, the which involves distorted or misinterpreted real perception; imagery, the which does not mimic real perception and is under voluntary control; and pseudohallucination, the which does not mimic real perception, but is not under voluntary control. [1Hallucinations also differ from "delusional Perceptions", in the which entered correctly sensed and interpreted a stimulus (ie a real perception) is given some additional (and typically bizarre) significance.

Nursing Interventions for Hallucinations or Delusions

Do not focus on hallucinations or delusions. Do interruption to the client by initiating interaction hallucinations one-on-one based on reality.

Tell them that you do not agree with the perception of the client, but the validation that you believe that the hallucinations are real to the client.

Do not argue with the client about the hallucinations or delusions.

Respond to the feelings that the client communicated at the time he was having hallucinations or delusions.

Divert and focus the client on a structured activity or task-based reality.

Move the client to a more quiet, less stimulating.

Wait until the client does not have hallucinations or delusions before starting the counseling session about it.

Explain that hallucinations or delusions are symptoms of psychiatric disorders.Say that the anxiety or increased stimulus from the environment, can stimulate the onset of hallucinations.

Help clients control the hallucinations by focusing on the reality and take medication as prescribed.

If hallucinations persist, Help clients to ignore it and keep acting remedy properly despite an hallucination.

Teach a variety of cognitive strategies and tell the client to use conversations themselves ("the voices that makes no sense") and the cessation of mind ("I will not think about it").

After nursing actions during 2x24 hours expected of patients with expected outcomes:(161 102) Position the patient to improve eyesight.(161 103) Instruct family members to use the techniques improve eyesight(161 107) Use visual aids(161 105) Use goggles

NOC criteria:

Not done at all

Rarely do

Are underway

Often performed

Always do

Cataract Nursing Interventions Classification NIC : EYE CARE (1650)

Monitor the redness and the presence of exudate

Determine the degree of decrease in vision or sharp eyesight test

Instruct patient not to touch eyes

Monitor corneal reflex

Instruct the patient to use glasses cataract

Take action to help patients deal with limited vision.

Encourage the patient to express feelings about the loss of vision.

2. Anxiety related to changes in health status

NOC : Anxiety Control (1402)

After nursing actions during 2x24 hours expected of patients with expected outcomes:(140 206) The use of effective coping strategies(140 207) Respiratory Rate within the normal range(140 211) There is an increasing social relationships(140 214) patients feel as comfortable with the situation(1402170) The patient was calm

NOC criteria:

Not done at all

Rarely do

Are underway

Often performed

Always do

NIC: Anxiety Reduction (5820)

Trying to understand the client's circumstances

Give information about the diagnosis and action

Use a calm approach

Identify the level of anxiety

Help patients recognize situations that indicate anxiety

Encourage patients to express feelings and fears

Give the drug to reduce anxiety

Assess the level of anxiety and physical reactions at the level of anxiety

Instruct the patient to reduce anxiety with relaxation techniques

Coping Enhancement (5830)

Use a calm approach and provide assurance

Appreciate and discuss alternative responses to situations

Support the involvement of families in an appropriate manner

Respect the patient's understanding of disease processes

Supports the use of appropriate defensive mechanisms

Provide a realistic choices about aspects of current treatments

3. Low self esteem related to Impaired self-image

NOC: Body Image (1200)

After nursing actions performed in 3 x 24 hours the patient is expected to receive him, with the expected outcomes:

Saturday, October 22, 2011

Dementia is a decline of reasoning, memory, and other mental abilities (the cognitive functions). This decline eventually impairs the ability to carry out everyday activities such as driving; household chores; and even personal care such as bathing, dressing, and feeding (often called activities of daily living, or ADLs).

Dementia is most common in elderly people; it used to be called senility and was considered a normal part of aging.

We now know that dementia is not a normal part of aging but is caused by a number of underlying medical conditions that can occur in both elderly and younger persons.

In some cases, dementia can be reversed with proper medical treatment. In others, it is permanent and usually gets worse over time.

About 4-5 million people in the United States have some degree of dementia, and that number will increase over the next few decades with the aging of the population.

Dementia affects about 1% of people aged 60-64 years and as many as 30-50% of people older than 85 years.

It is the leading reason for placing elderly people in institutions such as nursing homes.

Dementia is a very serious condition that results in significant financial and human costs.

Many people with dementia eventually become totally dependent on others for their care.

Although people with dementia typically remain fully conscious, the loss of short- and long-term memory are universal.

People with dementia also experience declines in any or all areas of intellectual functioning, for example, use of language and numbers; awareness of what is going on around him or her; judgment; and the ability to reason, solve problems, and think abstractly.

These losses not only impair a person's ability to function independently, but also have a negative impact on quality of life and relationships.

Many older people fear that they are developing dementia because they cannot find their glasses or remember someone's name.

These very common problems are most often due to a much less serious condition involving slowing of mental processes with age.

Although this condition is a nuisance, it does not impair a person's ability to learn new information, solve problems, or carry out everyday activities, as dementia does.

Types of Dementia

The Different Types of Dementia

Dementing disorders can be classified many different ways. These classification schemes attempt to group disorders that have particular features in common, such as whether they are progressive or what parts of the brain are affected. Some forms of dementia are classified as either primary or secondary dementia. Examples of primary dementia include:

Gastritis is not a single disease, but means inflammation of the stomach lining. Gastritis can be caused by drinking too much alcohol, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), or infection with bacteria such as Helicobacter pylori. Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections. Certain diseases, such as pernicious anemia, autoimmune disorders, and chronic bile reflux, can cause gastritis as well.

Symptoms of Gastritis

The most common symptoms are abdominal upset or pain. Other symptoms are belching, abdominal bloating, nausea, and vomiting or a feeling of fullness or of burning in the upper abdomen. Blood in your vomit or black stools may be a sign of bleeding in the stomach, which may indicate a serious problem requiring immediate medical attention.

Thursday, May 5, 2011

Adequate nutrition is necessary to meet the body’s demands. Nutritional status can be affected by disease or injury states (e.g., gastrointestinal [GI] malabsorption, cancer, burns); physical factors (e.g., muscle weakness, poor dentition, activity intolerance, pain, substance abuse); social factors (e.g., lack of financial resources to obtain nutritious foods); or psychological factors (e.g., depression, boredom). During times of illness (e.g., trauma, surgery, sepsis, burns), adequate nutrition plays an important role in healing and recovery. Cultural and religious factors strongly affect the food habits of patients. Women exhibit a higher incidence of voluntary restriction of food intake secondary to anorexia, bulimia, and self-constructed fad dieting. Patients who are elderly likewise experience problems in nutrition related to lack of financial resources, cognitive impairments causing them to forget to eat, physical limitations that interfere with preparing food, deterioration of their sense of taste and smell, reduction of gastric secretion that accompanies aging and interferes with digestion, and social isolation and boredom that cause a lack of interest in eating. This care plan addresses general concerns related to nutritional deficits for the hospital or home setting.

Nursing Intervention for Imbalanced Nutrition Less than Body Requirements

Pain is a feeling triggered in the nervous system. Pain may be sharp or dull. It may come and go, or it may be constant. You may feel pain in one area of your body, such as your back, abdomen or chest or you may feel pain all over, such as when your muscles ache from the flu.

Pain can be helpful in diagnosing a problem. Without pain, you might seriously hurt yourself without knowing it, or you might not realize you have a medical problem that needs treatment. Once you take care of the problem, pain usually goes away. However, sometimes pain goes on for weeks, months or even years. This is called chronic pain. Sometimes chronic pain is due to an ongoing cause, such as cancer or arthritis. Sometimes the cause is unknown.

Fortunately, there are many ways to treat pain. Treatment varies depending on the cause of pain. Pain relievers, acupuncture and sometimes surgery are helpful.nlm.nih.gov

Nursing Interventions for Pain

Increase knowledge

Explain the causes of pain to the individual, if known.

Linking how long the pain will last, if known.

Explain diagnostic tests and procedures in detail with a connecting discomfort and sensation will be felt, and the estimated duration of pain occur.

Provide accurate information to reduce fear.

Connect your acceptance of individual response to pain.

Recognizing the existence of pain.

Listen with full attention on the pain.

Shows that the pain you are because you want to understand better (not to determine if the pain is really there).

Sunday, May 1, 2011

Diabetes mellitus is a disorder in which the level of blood glucose is persistently raised above the normal range. Diabetes mellitus is a syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate. Diabetes mellitus occurs in two primary forms: type 1, characterized by absolute insufficiency, and the more prevalent type 2, characterized by insulin resistance with varying degrees of insulin secretory defects. Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both (ADA], Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 2003.

Nursing Intervention for Diabetes

Nursing Diagnosis

Impaired nutrition: less than body requirements related to the reduction of oral input, anorexia, nausea, increased metabolism of protein, fat.

Nursing Intervention

Objective :The patient's nutritional needs are met

Result Criteria :Patients can digest the amount of calories or nutrients appropriateStable weight or additions to the range usually

Intervention :

Weigh the body weight per day or according to the indication.

Determine the diet and eating patterns of patients and compare it with foods that can be spent on patients.

Auscultation bowel sounds, record the existence of abdominal pain / abdominal bloating, nausea, vomit that has not had time to digest food, maintain a state of fasting according to the indication.

Give the liquid diet containing foods (nutrients) and the electrolyte immediately if the patient has to tolerate it orally.

Involve the patient's family at this meal digestion according to the indication.

Observation of the signs of hypoglycemia, such as changes in level of consciousness, skin moist / cold, rapid pulse, hunger, sensitive to stimuli, anxiety, headaches.

Pneumonia, acute infection of the lung parenchyma, interstitial lung tissue in which fluid and blood cells escape into the alveoli. that often impairs gas exchange. Pneumonia classified in several ways.

Based on microbiological etiology origin:

Viral

Bacterial

Fungal

Protozoa

Mycobacterium

Mycoplasmal

Rickettsial

Based in location, pneumonia can be classified:

Bronchopneumonia, Bronchopneumonia involves distal airways and alveoliLobular pneumonia or lobar pneumonia. In this pneumonia involves part of a lobe; and lobar pneumonia, an entire lobe

The infection is also classified as one of three types:

Primary pneumonia

Primary pneumonia results directly from inhalation or aspiration of a pathogen, such as bacteria or a virus; it includes pneumococcal and viral pneumonia.

Secondary pneumonia

Secondary pneumonia may follow initial lung damage from a noxious chemical or other insult (superinfection) or may result from hematogenous spread of bacteria from a distant area.

Aspiration pneumonia

Aspiration pneumonia results from inhalation of foreign matter, such as stomach contents vomitus or food particles, into the bronchi. It’s more likely to occur in elderly or debilitated patients, those receiving nasogastric tube feedings, higher prevalence those with an impaired gag reflex, poor oral hygiene, or a decreased level of consciousness.

Quality of cough and ability to raise secretions including consistency and characteristics od sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.

Tuesday, April 26, 2011

NANDA Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associate with the creation of a nursing care plan. The NIC consists of a standardized list which contains 433 different interventions. Each intervention is defined and the definition describes a set of activities a nurse performs in order to perform one of the interventions. Each of the 433 interventions is coded into a three-level taxonomic structure consisting of 27 classes and 6 domains. The taxonomic structure allows for easy selection of an intervention and to classify them by means of a computer. The NIC also allows for the implementation of a Nursing Minimum Data Set (NMDS). The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, and is HL7 registered.

Monday, April 25, 2011

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